While inserting a rectal thermometer, the nurse encounters resistance. Which should the nurse implement?
1. Remove the thermometer immediately.
2. Ask the client to take a few deep breaths.
3. Apply mild pressure to advance thermometer.
4. Remove the thermometer and reinsert gently.
2
2. While inserting a rectal thermometer, the nurse instructs the client to take a few breaths to relax rectal sphincters that contract on initial pressure and, then, relax dur-ing exhalation. As the client exhales, resistance should decrease to allow safe passage of the thermometer into the client's rectum.
1 and 4. If the nurse removes the thermometer, the stimulation reactivates the sphincter reflex and the nurse will need to instruct the client again to take a few deep breaths.
3. Applying pressure to advance the thermometer is contraindicated to prevent com-plications.
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